This is a question that has been central in my thinking since the advent of “Managed Care” in the late 80’s. Of course, most of you have known nothing else but this style of “care”. Or else you have forgotten what things used to be like. Once upon a time, there was an era when the doctor and the patient had a direct clinical, personal, and financial transaction with each other. Gone are the days of the trust, respect, and responsibilities that accompany such a direct relationship.
It was an era when third party payers and giant hospital and health provider networks were not in control of healthcare. This was back when a “referral” was a personal introduction of you, the patient, by your family doctor to a trusted specialist. Nowadays a “referral” means a number and a code provided by the insurance company.
I could go on with other features of the Managed Care world, but instead let me give you the examples of two other well-known social institutions that also are suffering in much the same way as healthcare. The core paradigm here is the mistaken notion that centralizing a “system” for providing a particular set of services or goods improves the quality, standards, and thus the value of said services and goods.
First, let me start with the Education System. For all the well-intentioned goals espoused by the central party planners, (don’t get me wrong, high standards ARE important), it seems that government-mandated curriculum standards are turning education into a “Common Corpse”. (I have applied this less-than-complementary moniker to our education bureaucracy many times, always to the hearty approbation of the literally dozens of teachers who are patients of mine.)
Today’s teachers have found their pedagogical gifts constrained and strangled by narrow curriculum and testing requirements. Their teachers’ “scorecards” are evaluated and enforced by nervous principals, themselves overseen by even more nervous county administrators, who in turn answer to implacable government bureaucrats, the ones who hold the local school system’s financial fate in their hands. “No Paperwork Left Behind”, that’s what I call it. And my teachers all say: “Amen”.
The highest quality education I ever received was from teachers who ignored the system and CARED about their subject. Take my Latin teacher, Georgia Frothingham, for example. Here was the wizened, wrinkled, shriveled embodiment of the ancient schoolmarm. I can still see her at the front of the room and hear the mantra with which she opened every class: “LATIN,” she would intone dramatically, “is NOT a DEAD LANGUAGE!!!” Her enunciation was so precise that she sssspat when she sssspoke, spewing a rancid vapor of burnt coffee and stale cigarettes with each clipped consonant. Her words were exquisitely ejaculated from between her pursed and deeply creased lips that stretched to barely cover protruding yellow incisors, stained by nicotine and caffeine. Picture the mummy of Queen Nefertiti.
But she LOVED Latin. She loved her students. And we loved her.
She also LOVED Julius Caesar; the sole content of her upper level curriculum was the reading and translation of Caesar’s Gallic Wars. She poked fun at her personal antiquity, confessing that she was SO OLD that she had been, in actuality, Caesar’s last lover. On the Ides of March she would spend an entire week in deep mourning, draping herself, and her classroom, in funereal black.
It was because of her that my verbal SAT scores were so high. She was the first to pass a love of language and grammar on to me. It is to her teaching of Latin that I owe the beginnings of an adequately expressive vocabulary.
And there was “Terrible Tom Turner”, my first college physics professor. On the very first day of class he filled up three walls of blackboards with one Psi function equation after another, whirling like a Dervish and waving his arms excitedly the whole time. At the end of the dizzying calculus (which a few of us could follow in the most rudimentary way) he punched the stratosphere with an ecstatic, nay, euphoric flourish, then underlined the solution to the equation: E =MC squared… Einstein’s Theory of Relativity. (half the class quit that day, but those of us who stayed were treated to a semester of mind-bending and sometimes grueling wonder). I should say that of the 13 of us who finished the semester with him, five went on to become PhD’s in physics. Dr. Turner passed on no small amount of love and CARE for his discipline to others.
Enough about school.
Let’s talk about another “system”. The Justice System. Our justice system is arguably the best there has been in recorded history, but no one would contend that what comes out of it is always just. It often seems that if one knows how to work the “system”, or is fortunate to find someone within it who actually cares, or who has enough money to pay a lawyer to at least act like he cares, (you can fill in some familiar celebrity names here, if you like) one may get justice…. or at least the desired outcome.
We now live in a time where increasingly federalized judicial rulings become the controlling forces of laws, statutes, and even local ordinances. Centralized control of the administration of justice results an increasing arbitrariness, fecklessness, and, frankly, absence of common sense within the legal system. Don’t get me wrong, real justice often does ensue from the involvement of the justice system in the course of human interactions and the conflicts that arise therefrom.
But for actual justice to come to pass of necessity requires that the participants in any particular judicial process CARE about, well…. JUSTICE.
Having sat on a jury more than once, I saw the best aspects of the system in action. We followed the rules. The attorneys did an admirable job of spinning their stories according to the regulations and restraints of the courtroom. After we had rendered our “guilty” verdict, the wise old judge was kind enough to spend an hour or more with us jurors. Though we had agonized over our decision, he gave us the inside story. He explained that we had done the right thing, according to the evidence. Then he revealed to us that other important but legally inadmissible details had been withheld from us, details that would have made rendering a guilty verdict a much easier thing. But the law was followed. The “system” worked. Justice was served in this instance and I am proud to have been a part of it.
In this case, I was exposed to professionals who CARED about the rule of law. But as it is heading now, it seems the “justice system” is less and less able to deliver justice.
So now we come to the Healthcare SYSTEM. For all the hype about “working together” and developing so-called “Integrated Delivery of Care” (that’s a code word for “we own all the doctors and facilities in the area”) these “systems” are not able to offer any convincing proof that they improve quality of care for people.
Have you noticed that Healthcare is centralizing and consolidating like everything else?
Hospital systems are merging, buying up medical practices, specialist and primary care alike. Insurance companies are merging. These days, the cost of healthcare is determined by the negotiated “smoke-filled-room” contracts between the “big boys”, the BIG PROVIDERS, and the BIG PAYERS. Gone are the days when the individual patient has the power to determine what value in healthcare is. By “value” I mean the best care at the lowest price. The patient-doctor relationship these days does not function as a free market economy.
Again, don’t misunderstand. Real healthcare does get delivered within our SYSTEM. But it is mostly the work of individuals who care and the not product of an efficient and cost-effective system. Just as real education happens in the education system, despite rules and restrictions and often outright prohibition of the free exchange of ideas. Just as true justice is administered by the legal system, despite poorly written laws, skillful manipulators, or judicially distorted higher court interpretations of the Law. Quality healthcare is delivered by individuals who care.
Nine years ago, 65% of primary care doctors were in solo practice or small groups nationwide. Today, that number is around 25%. Why? Because smaller players who formerly could thrive in a direct one-on-one healthcare delivery world are being squeezed out. The big groups control the best contracts.
When a primary care doctor goes to work for a big player (a hospital or big clinic), his or her performance (and paycheck) are determined by a thing called “RVU’s” (relative value units). In plain English this means the doctor gets paid according to production; “how many patients can you run through the turnstiles today, Doctor?”
Care takes time. Time is money. There is no money in the current system for primary care doctors (or any caregiver, for that matter) who takes his time.
That’s where the care went.
End of story.